if they went to some of our State schools also and save us a little bit of money, aside from the factor that if they are there, they tend to stay there. And you are right, once they leave they do not come back.

And that is why we need to encourage the scholarship program, and we are going to take another look at this, specifically, because last year we reauthorized the National Health Service Corps. And we specifically changed the law or wrote into the law under the authorizing committee, Senator Kennedy's subcommittee, to make sure that we specified underserved areas. We did not focus on urban areas or anything else like that. We focused on underserved

areas.

And, quite frankly, I am concerned that the Department is going off in a different direction than what we clearly put in the law last year. And so I just want you to know, Senator Bumpers, on the record, that we are going to take a close look at these scholarships and make sure that we start getting them out to those rural areas out there and not just to the urban areas.

Dr. HARMON. Thank you, Mr. Chairman.

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

Senator HARKIN. Thank you very much, Dr. Harmon, and we will be in touch as the year goes along. There will be some additional questions from various Senators which we will submit to you for

your response.

[The following questions were not asked at the hearing, but were submitted to the Department for response subsequent to the hearing:]

QUESTIONS SUBMITTED BY THE SUBCOMMITTEE

OTA CALLS FOR MORE OF THE CORPS IN RURAL AREAS

The Office of Technology Assessment issued a comprehensive report last September called "Health Care in Rural America." The report notes that rural health care is no better today than it was 20 years ago, and says "the future prospect for rural health care in the absence of intervention is grim."

The OTA calls for a massive expansion of the National Health Service Corps to increase the supply of health professionals to rural areas.

Question. Are the Department's current policies regarding scholarship awards likely to have a significant impact on rural areas? If not, what are ways to bring many more health professionals to rural areas, both through the National Health Service Corps and other Federal programs, such as Medicare reimbursement?

Answer: Yes, the expansion of the National Health Service Corps scholarship and loan repayment programs which began last year will provide substantial numbers of new obligors for both rural and urban areas, although the immediate impact will be limited to increases in the number of Federal and State loan repayment obligors. Increasing the number of scholarship obligors available for service will require several years while the current awardees complete their training. The scholarship mechanism is an effective mechanism for attracting providers to the more difficult to fill sites, especially the remote rural sites. It is hoped that the State loan repayment program, for which a large increase will be provided in FY 1991, can become an effective source of health care providers for rural States. Funds are also included for the support of State cooperative agreements to facilitate the identification of areas within States that are in need of Federal assistance and also to assist States in being more effective in obtaining Federal assistance for their primary health care programs.

NATIONAL HEALTH SERVICE CORPS

Question. If the FY 1992 budget request is approved, how many health professionals of which disciplines would be placed through NHSC scholarship and loan repayment programs?

Answer. In FY 1992 it is projected that 285 loan repayment obligors will be recruited and placed including physicians, nurse practitioners, nurse midwives, and physician assistants. Approximately 500 scholarships are projected for FY 1992, although the placement of individuals supported from these awards must await the completion of their training which, for physicians, takes from 6 to 7 years following the initial year of support. About 175-180 of these will be non-physicians for whom the training period is much shorter. We expect to place fewer than 50 scholarship obligors in FY 1992 available as a result of awards made in previous years.

Question. How many additional HPSAs would be eliminated as a result of the program expansions? What proportion of the HPSAs

would be eliminated in rural areas, IHS sites, inner-city areas, of at Federal facilities?

Answer. For the current year there are over 200 scholarship HPOL sites of which 73 percent are rural. About 74 percent of the total are in community or migrant health centers 20 percent are in on IHS reservations and 6 percent are in Bureau of Prisons facilities. The placement of NHSC obligors in a HPSA to repay their service obligation would not contribute to the de-designation of that HPSA. In fact, an obligor can only fulfill their obligation if they serve in an area that retains its HPSA designation. Only if, after the service obligation is completed, the former NHSC obligor chooses to continue to remain and deliver health care in that HPSA, would the provider be counted in the physician to population ratio used in determining the HPSA designation.

Question. How much additional funding would be required for the scholarship and loan repayment programs to eliminate all existing HPSAs in the next two years?

Answer. The assignment of obligated providers does not eliminate the designation but would provide service on an interim basis until a provider is permanently located in the area. To recruit the necessary number of obligors to reach an NHSC field strength by the end of FY 1993 equal to the 4,400 primary care practitioners required in HPSA's would cost on the order of $250 to $300 million. This estimate assumes that the additional primary care providers required by the end of FY 1992 would be recruited under the NHSC loan repayment program.

It is not reasonable to expect, however, that the only mechanism that would provide obligors for service in the given time frame, the loan repayment program, would be sufficiently attractive that it would be possible to recruit and assign the requisite number of providers within the next two years in order to resolve all 2,000 primary care HPSA.

The request before you will permit very substantial progress in addressing the problem of health provider shortages in rural and certain urban areas. This progress will accelerate once the supply of scholarship obligors is reestablished. However, the ultimate solution to the problem will require increased retention of obligors after the obligation has completed, attracting non-obligated individuals, the restoration of the scholarship pipeline, and the expansion of the State loan repayment program over the next several years.

Question. What have recent program evaluations indicated about the effectiveness of the NHSC programs?

Answer. Although there are no recent formal studies, it has been learned over the past few years that the most reliable method of attracting health professionals is the scholarship program which has now been reestablished through in the FY 1991 and FY 1992 budgets. Other approaches which have been emphasized in recent years, such as the Federal and State loan repayment programs, are demonstrating their success in attracting providers to many less hard to fill underserved areas. We expect these loan repayment rograms to become more attractive, especially to physicians with

educational loan balances totalling $85,000 or more, if loan repayments can be made in lump-sums early in the repayment period which will dramatically reduce the borrower's outstanding balances and associated interest.

MATERNAL AND CHILD HEALTH

Under provisions of OBRA 89, State MCH block grant programs are required to improve the health of mothers and children consistent with the Healthy People 2000 national health goals and objectives.

Question. What steps has HRSA taken to assure that States are implementing these goals and objectives in their MCH programs?

Answer. OBRA 89 amendments to Title V of the Social Security Act significantly changed the Maternal and Child Health (MCH) Block Grant program to improve State's planning and accountability and to make it consistent with the Year 2000 health goals and objectives.

Among the changes to the Block grant was the requirement that the States submit an application for their Block grant allocations. The application, among other requirements, must include a statewide needs assessment and a plan for meeting the identified needs. Upon enactment of the legislation the Maternal and Child Health Bureau (MCHB) quickly prepared and issued application guidance material to the States. MCHB provided technical assistance to the States through a series of meetings informing the States of the new requirements of Title V and providing assistance in preparing their applications. The Bureau established an effective system to ensure that the applications were received, processed, and reviewed in time to make awards at the beginning of the fiscal year, when funds became available.

Another major change to the MCH Block Grant program is the requirement that States, beginning in FY 1992, report on data and information describing the extent to which the State has met the Year 2000 goals and objectives for maternal and child health. The MCHB has actively engaged the States in assisting them to meet their reporting requirements. In the FY 1991 application guidance the MCHB identified explicit data elements and variables for which reporting would be necessary and even cited known source of data when possible. Many of the States provided information related to their plans for annual reporting in FY 1991 and identified areas in which the acquisition of data would be difficult. This information has been utilized by MCHB in identifying areas in which technical assistance in the data area will be required. MCHB staff will be conducting on-site technical assistance in the States on the reporting requirements.

STATE OF THE UNION

Dr. Harmon, I'd like you to present the Subcommittee with a picture of access to health care services today. I understand you have a map that shows this information.

Question. In rural areas of the country like my state, is access to primary care services getting better or worse?

Answer. Several measures available to us indicate that access to primary care services in rural areas may not be improving despite significant increases in the total number of physicians practicing in the nation. In 1988, urban counties had almost twice the number of primary care physicians per 10,000 persons as rural counties (8.7 compared to 5.5). In 1988, all of the 111 counties (with a resident population of 325,000) with no M.D. or D.O. were rural. In that year 29 percent of all rural residents were living in federally designated primary care Health Manpower Shortage Areas, compared with only 9.2 percent of urban residents. Moreover, from 1979 to 1988, when the number of active physicians increased 35 percent in the U.S., primary care physicians practicing in the most vulnerable rural communities (those with 10,000 or fewer people) only increased 20 percent.

NATIONAL HEALTH SERVICE CORPS

Dr. Harmon, I want to ask you some questions about the National Health Service Corps. I spent a lot of time last year on the legislation reauthorizing the Corps, and in my position as Chairman of this Subcommittee, provided the Corps its largest funding increase in the last decade. This program means a lot to rural states like mine, and I want to make sure it's fulfilling its mission:

Question. Dr. Harmon, I've been told that the single most important factor that influences where doctors choose to practice has to do with where they are trained. Do you agree?

Answer. It is probably the most important single factor, yes.

Question. What are the implications for states like mine of spending most of the scholarship funds at just a few East Coast schools?

Answer. Although most scholarship awardees did attend schools on the east coast, by no means did all students, and certainly not in just a few schools. For example, of the 13,800 scholars receiving support, 800 attended schools in California. The school which had the largest number of NHSC scholars is Meharry Medical College in Tennessee. The top ten schools trained only about 20 percent of the total number of obligors.

However, because scholarship obligors must be assigned to areas of highest need, they select assignment from a list of sites developed by the NHSC based on an assessment of need. These sites are usually remote rural or underserved urban areas. Therefore, during the period of obligated service, where the individual is trained is of lesser influence than when physicians are able to make choices without consideration of a service obligation. The long term solution to the problem of health professional shortages in States like yours depends on finding ways to retain practitioners after their obligation is complete.

Question. With the large funding increase we provided, how many positions do you expect to fund in FY 91, and how can this Subcommittee make sure that Iowa and other rural states get their fair share?